Myocardial injury in meningococcus-induced purpura fulminans in children

Objectives: To assess the incidence of myocardial ischemia in meningococcus -induced purpura fulminans in pediatric patients, to compare troponin I (cT nI) levels with changes in electrocardiogram (ECG) and to evaluate whether cTnI is related to myocardial function and contractility, to severe acquire d anticoagulant deficiency and to the severity of disease. Methods: Twenty-two patients with acute meningococcemia supported with inot ropes or vasoactive agents, were studied. Blood samples for the determinati on of serum cTnI and conventional myocardial ischemia and coagulopathy mark ers were drawn daily. Measurements of cardiac index (CI), ejection (EF) and shortening fractions (SF) and ECGs were performed daily. Results: The Leclerc score, the Neisseria sepsis index (NESI) and the pedia tric risk of mortality (PRISM) score predicted a mean mortality rate of 34% , 27% and 23%, respectively. Four patients died (18%). Five patients (23%) presented with myocardial ischemia. Their ECG ischemic changes were associa ted with pathologically high cTnI levels (1.93 +/- 0.13 vs 0.18 +/- 0.08 ng /ml, p < 0.001 for patients with or without ischemic changes) and depressed myocardial contractility (mean difference +/- SE -14 +/- 5%, p = 0.01, for the EF and -7.4 +/- 3, p < 0.02, for the SF). High cTnI values were signif icantly correlated to low protein C (PC) (p < 0.0001), factor VIII (p < 0.0 4) and antithrombin III (AIII, p = 0.01) levels, but not to the PRISM, Lecl erc or the NESI scores. Means of AIII, VII, and especially of VIII, and PC, were significantly lower in ischemic than in non-ischemic patients, althou gh severity scoring systems and inotropic support did not differ between th e two groups. Survivors tended to significantly higher PC (p < 0.01) and fa ctor VIII levels (p = 0.001) than non-survivors and, also, to lower levels of cTnI (p = 0.05) and CPK-MB (p < 0.05), while in meningococcal shock. Conclusions: The incidence of myocardial ischemia is increased in acute men ingococcemia in pediatric patients and correlates with myocardial dysfuncti on. High cTnI is associated with severe coagulopathy, but not with clinical prognostic scores or inotropic support. Early recognition of myocardial in jury, myocardial support and early replacement therapy with PC, AIII, facto r VIII or fibrinogen might improve outcome in acute meningococcemia in chil dren.